I am going to start this article with the statement by Stephanie Okereke, the central actress of the movie DRY shot to campaign against early child marriage and consequences of VVF in Nigeria.
“People make the mistake of thinking that you only find people with Vvf in the North; I have been to Owerri, Aba, and many other southern cities in Nigeria and I have seen women who are affected with VVF.”
The World Health Organisation (WHO) described fistula as “the single most dramatic aftermath of neglected childbirth.”
- Vvf means vesico-vaginal fistulae
- It is an abnormal connection between the bladder and the vaginal causing leakage of urine
- Nigeria has the highest prevalence rate of vvf in the world
- About 90% of vvf in Nigeria is from obstructed labour
- 80,000 Nigerian women suffer vvf annually- United Nations
- Incidence and prevalence is high in Eastern and Northern Nigeria
- Ebonyi, a state in Eastern Nigeria tops the list of vvf victims.
- Women with vvf are stigmatized and socially isolated
- They need our care and compassion
- It has psycho-social consequences and reduces the quality of life of women
- Laws against child marriage will reduce vvf in Nigeria by about 40%
- We all have a part to play prevention and control of vvf in Nigeria.
Incidence of vvf in Nigeria
The real incidence of this condition is not known but available health facility data show that an estimate of between 400,000 and 800,000 cases with an annual incidence of 4 per 1000 deliveries, meaning 80,000 Nigerian women suffer annually. VVF is found in all parts of Nigeria but the prevalence is more in South-East, North-West, North-Central, North-East, and South-South geopolitical zones respectively. In these zones, there are vvf centres that do between 500 and 1500 vvf surgeries year.
Causes of vvf in Nigeria
Various vvf statistics in Nigeria points to the headers below as responsible for the high prevalence of vvf in our country.
Researches have shown that about 90% vvf in Nigeria is from obstructed labour due to cephalopelvic disproportion (misfit between the fetal head and the birth canal). Poor or no antenatal care during pregnancy, lack of transport and poverty (cannot afford caesarean section) are some of the causes of obstructed labour in Nigeria.
Abdominal surgeries and instrumental deliveries
Rupture of the uterus may sometimes be associated with a tear in the bladder especially if the bladder was adherent to a previous caesarean section scar. The bladder may be injured during operative vagina deliveries, caesarean section or caught in sutures during abdominal surgeries leading to fistula formation.
Female genital mutilation
Female genital cuttings are common traditional practices among many communities in Nigeria. These include removal of the clitoris and other forms of female circumcision, “yankan gishiri or angurya”. The latter involves the incision of the vaginal walls in obstructed labour with the hope that the incision would enlarge the birth canals.
DO YOU KNOW? Female genital cutting can cause tetanus.
Harmful traditional practices
Coital injuries from early marriages and packing the vagina with caustic salts are implicated in the causes of vvf in Nigeria.
Penetrating vaginal injuries, pelvic fractures from road traffic accidents and crude attempts at induced abortion causes pelvic injuries that may lead to leakage of urine.
Cancer and radiotherapy
Cancers of the genital tract, bladder and rectum can result into fistulae when advanced. So is irradiation(radiotherapy) from treatment of cancer of the cervix or the vulva.
Though very rare, lymphogranuloma venereum, a sexual transmitted infection caused by Chlamydia trachomatis may cause leakage of urine in women. During vulval ulceration associated with lymphogranuoma, the urethra may be amputated down to its junction with the bladder leaving a vvf.
The causes of vvf in Nigeria are summarized by a table below showing a study in a VVF centre in Jos.
|Causes of vvf||No of patients||%|
|female genital cutting
|pelvic injuries from trauma||4||0.4|
Table showing causes of fistulae in patients seen at the Evangel VVF centre, Jos. Leakage of urine was caused by obstructed labour in 781 vvf victims.
Social and economic consequences of vvf in Nigeria
Vvf is not without a social complication but, the social and economic consequences have received scant attention. Fistulae are not only extremely painful but also uncomfortable. It is one of the most dehumanizing afflictions of women. The shame of social isolation can lead to depression, divorce or even suicide. For example, in a study reported from northern Nigeria, the divorce rate following vvf was 65% as women with vvf are deserted by their husbands, relatives consider them as having brought shame to the family. The smell of urine makes them socially unacceptable, coupled with loss of self-esteem. Ultimately, abandoned by husband and rejected by family and sometimes their religion, they then leave their places of abode and become destitute until the fistula is repaired.
Women suffering from pelvic injuries and foot drop have difficulty in completing daily tasks as carrying water or firewood or caring for the children. Consequently, they are viewed as a burden to the family. The women are unable to be sexually active, or her infertile. It must be noted that since young women giving birth for the first time seem rather prone to vvf, they may have no living children due to subsequent complication of infertility.
Furthermore, the effect of vvf on the immediate family has never been considered. It seems likely that the husband would feel a sense of either guilt or may subconsciously or otherwise attribute the problem to infidelity. Even when they have had a successful repair, dyspareunia (pain during sexual intercourse) from scarred operation site may still be a problem.
Now, since Caeserean sections are advocated for all subsequent deliveries, all pregnancies are now high risk.
Prevention of vesico-vaginal fistula
VVF is the unhidden humiliating indicator of the terrible outcome among women in Nigeria whose prevention involves everybody i.e. government, spirited individuals, private bodies, non-governmental organizations, and religious houses. The prevention and control strategies of vvf are in the headers below:
Safe motherhood initiative
Vvf tells the untold story of unsafe motherhood. Safe motherhood initiative therefore carves the way for prevention of vvf and maternal death. Safe motherhood means social equity for women, antenatal care for all, emergency obstetrics for those in need, and family planning for the couple. One can also add that there must be strategies to warrant survival of the born children and reduce the temptation of high parity. It can therefore be said without fear of contradiction that VVF from obstructed labour is preventable. This is borne out of the fact that it disappears once the socio-economic circumstances of any community improve.
Education of the masses is one certain ways of reducing the prevalence of vvf in Nigeria. Education will create awareness in the minds of the patients to utilize the health care facilities that exist and make them deliver in hospitals as opposed to traditional birth attendants. It will also enable the very young adolescents who are the worst victims, to marry much later when they are bigger and more mature to start child bearing.
evangel vvf centre in jos,northern nigeria. Credit:premium times
Provision of basic obstetric care
Another way of reducing vvf in Nigeria is by making available basic but quality obstetric care at all levels so that cases at risk can be identified early and referred in time to vvf centres where labour complications can be dealt with. These secondary referral centres must be made accessible and functional with the right staff and equipment.
Making family planning available, accessible, and affordable for the couple will allow pregnancy by choice and not by coercion.
Legislation against child marriage
Legislation and enforcement of laws will reduce the prevalence of vvf in Nigeria by about 40%. It will make pregnancy safer.
Finally, empowerment through improved agriculture, communication network, and training of medical personnel and trained birth attendants in the skills of management of obstructed labour will ensure an early attainment of this goal. In this regard, cooperation of policy makers, administrators, and health workers in the community would be required.
Where can women suffering from obstetric fistula get help in Nigeria? I have been able to compile reputable Vvf centres in Nigeria that they can get comprehensive treatment below:
Vvf centres in Nigeria
Evangel VVF Centre, Jos, Nigeria.
National Obstetric Fistula Centre, Ningi, Bauchi, Nigeria.
Fistula Foundation Nigeria, Kano, Nigeria.
National Obstetric Fistula Centre, Bubbar Ruga, Katsina, Nigeria.
Laure Fistula Centre, Kano, Nigeria.
Kebbi VVF Centre, Birnin Kebbi, Nigeria.
Gesse VVF Centre, BIrnin Kebbi, Kebbi, Nigeria.
Maryam Abacha Women and Children’s Hospital, Sokoto, Nigeria
Faridat Yakubu General Hospital, Zamfara, Nigeria.
Jahun VVF Centre, Jigawa, Nigeria.
Kwara State Specialist Hospital, Sobi, Ilorin, Nigeria.
Adeoye General Hospital, Ibadan, Oyo, Nigeria.
University College Hospital, Ibadan, Oyo, Nigeria.
National Obstetric Fistula Centre, abakaliki, Ebonyi, Nigeria.
Ebonyi State University Teaching Hospital, Ebonyi, Nigeria.
Ogoja General Hospital, Cross River, Nigeria.
Family Life Centre Hospital, Mbrebit Itam, Uyo, Akwa- Ibom, Nigeria.
University of Benin Teaching Hospital, Ugbowo, Benin-city, Nigeria.
These vvf centres also serves as treatment and referral centre for neighbouring African countries in Chad, Niger, Mali e.t.c.
RESOURCES: 1.Textbook of obstetrics and Gynaecology by Akin Agboola
2. Clinical Gynaecology by Eugene Okpere